Journal of Investigative and Clinical Dentistry (2016), 7, 65–71
ORIGINAL ARTICLE Oral Medicine
Influence of highly-active antiretroviral therapy on the subgingival biofilm in HIV-infected patients Rainer A. Jordan1, Adrian Lucaciu2 & Stefan Zimmer1 1 Department of Operative and Preventive Dentistry, Faculty of Health, Witten/Herdecke University, Witten, Germany 2 Private Practice, Cologne, Germany
Keywords antiretroviral drug, highly-active antiretroviral therapy, HIV infection, periodontal disease, subgingival biofilm. Correspondence Dr Rainer A. Jordan, Director, Institute of German Dentists (IDZ), Universitaetsstrasse 73, Cologne D-50931, Germany. Tel: +49-221-4001-145 Fax: +49-221-404886 Email: [email protected] Received 8 July 2013; accepted 27 July 2013. doi: 10.1111/jicd.12124
Abstract Aim: Highly-active antiretroviral therapy (HAART) has been associated with alterations in subgingival biofilm and periodontal disease. The purpose of the present study was to investigate the association between different HAART regimens and the prevalence of periodontal pathogens in HIV-infected patients with chronic periodontitis. Methods: Subgingival periodontal pathogens were determined by a DNA chip microarray in a case series in 14 HIV-infected patients receiving HAART with different drug combinations: protease inhibitor (PI)-based HAART versus nonnucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. A statistical analysis was conducted to determine whether specific HAART regimens were associated with 10 periodontal pathogens using odds ratios (OR). Results: At baseline and after treatment, the patients did not show significant clinical and immunological differences. In general, the highest OR for the prevalence of periodontal pathogens were found in the PI HAART group for Actinomyces viscosus (A. viscosus) (OR: 303), Campylobacter rectus (OR: 90), and Treponema denticola (OR: 25). In the NNRTI HAART group, higher OR were documented for Fusobacterium nucleatum (OR: 56) and Eikenella corrodens (OR: 25). The association between A. viscosus and PI HAART was statistically significant (P = 0.03). Conclusions: The results demonstrated statistical associations between subgingival bacteria and antiretroviral drug therapies. Further investigation on the clinical significance and underlying mechanisms are needed to support these findings.
Introduction Microbiological studies in HIV-infected patients have been conducted since the beginning of the worldwide epidemic, but less is known about antiretroviral drug influences on periodontal pathogens. The scientific investigation of the subgingival biofilm in HIV-infected patients can be divided into different stages. First, investigations before 1996, the time of the development of highly-active antiretroviral therapy (HAART), when periodontal pathogens were studied in the natural progression of HIV infection; second, investigations after 1996. Pre-HAART results have demonstrated a high prevalence of periodontal diseases, especially acute forms, such as necrotizing ulcerative gingivitis and periodontitis, ª 2014 Wiley Publishing Asia Pty Ltd
accompanied by high levels of periodontal and atypical microbiota.1,2 HAART has shifted HIV infection into a chronic disease, with a significantly decreased mortality and improved quality of life.3,4 This includes a changing prevalence in HIV-related and AIDS-indicating diseases of the oral cavity, such as Kaposi sarcoma, but also new HIV-related oral lesions, such as oral warts.5,6 However, the overall preventive fraction of HIV-related oral lesions in patients undergoing protease inhibitor (PI)-based HAART is approximately 30%.7 Bacterial and fungal infections, in particular, decreased significantly under HAART, whereas oral lesions of viral or autoimmune origin, as well as neoplasia, have been found to have a significant impact in some populations.8 Scientific evidence of the role of specific antiretroviral drugs, such as the key medicine protease 65
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inhibitors and non-nucleoside reverse transcriptase inhibitors (NNRTI), is inconsistent. Protease inhibitors are widely investigated, demonstrating a significant effect in preventing HIV-related oral lesions compared to PI-sparing drug regimens.9 For instance, several clinical and in vitro investigations have demonstrated a direct, immune reconstitution-independent effect of PI on the prevalence of oral candidiasis.10 In a Brazilian cohort, HIV-infected patients with chronic periodontitis undergoing HAART showed even less periodontal inflammation and destruction, as compared to a HIV-seronegative control group with chronic periodontitis. This effect was also obvious in patients on semi-optimal HAART with immunosuppression and detectable viremia, indicating that there might be a HAART-dependent protective effect in the clinical course of periodontal diseases, as well as general immune reconstitution. The study also revealed a significant difference in the subgingival bacterial load and elevated levels of microbiota of the red and orange complex in the HIV-seronegative control group for the benefit of HAART patients.11 However, it was also shown that reverse transcriptase inhibitors (RTI) are able to compromise periodontal health,12 and epidemiological studies have shown significantly more HIV-related oral lesions in patients on PI HAART compared to those taking an NNRTI HAART, with twice the amount of oral lesions.13 The findings indicate an influence of HAART drug regimens in the development of HIV-related oral lesions, particularly bacterial infections. Microbiological investigations of the subgingival biofilm composition in HIVinfected patients undergoing HAART have demonstrated clear differences compared to an HIV-seronegative control group,11 yet no data are available concerning the potential influence of different antiretroviral key drugs (PI, NNRTI) on periodontal pathogens, restricting the development of a working hypothesis. Therefore, the aim of this preliminary investigation was to analyze differences in the subgingival profile of HIV-infected patients with chronic periodontitis on supportive periodontal therapy (SPT) undergoing different HAART regimens to generate a working hypothesis for a prospective clinical study. Material and methods Patients attending an outpatient HIV oral health care center in Berlin, Germany, who were undergoing HAART for at least 6 months, and who had chronic periodontitis, were asked to participate in the study. They were recruited within a time slot of 12 months, meeting the primary inclusion criteria (HIV-1 infection and NNRTI or PI as a key drug of HAART; n = 92). Periodontal disease was defined as a minimum of four teeth with periodontal probing pocket depths ≥4 mm.14 Periodontal examination was 66
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performed using a PCP 12 periodontometer (HuFridey, Chicago, IL, USA) by a calibrated examiner (intra-examiner reliability: K = 0.91). After screening for the secondary inclusion criteria (chronic periodontitis with at least 4 teeth with probing pocket depths of ≥4 mm and younger than 45 years of age), 14 patients met the initial inclusion criteria for participation. Of these, 11 concluded the study. Exclusion criteria were the presence of other systemic disorders associated with chronic periodontitis, such as diabetes; patients taking antibiotics at least 3 months prior to the examinations, at baseline, and after treatment; and a lack of compliance concerning SPT and informed consent, respectively. The patients were periodontally treated according to a standard therapy protocol. Scaling and root planing was performed by a single operator, and SPT by a single dental hygienist, respectively. After three appointments of an initial hygiene phase with professional tooth cleaning and oral hygiene instructions at 2-week intervals, the baseline measurement of clinical parameters of periodontal, hematological, and viremic data was done (Table 1). Subsequently, scaling and root planing was performed in all teeth with periodontal probing pocket depths ≥4 mm, followed by SPT with an appointment schedule according to the individual risk profile. Approximately 10.6 months after scaling and root planing and 3 months prior to study commencement, patients were rescreened for antibiotics; three patients were excluded from the study. Clinical characteristics were rerecorded, 10 periodontal pathogens were detected by a DNA chip microarray, and statistical analysis was performed (Figure 1). Measurement of periodontal pathogens The detection of periodontal pathogens was executed with ParoCheck 10 (Greiner BioOne GmbH, Frickenhausen, Germany). According to the recommendations of Haffajee and Socransky15, biofilm samples were taken for 15 s in the four deepest pockets with sterile paper tips. Twenty-eight unpooled samples in seven patients with NNRTI HAART, and 16 unpooled samples in four patients with PI HAART, were thus obtained from sites with previous scaling and root planing. They were transferred into sterile collection tubes, and transported to the microbiological lab at room temperature. The test principle of the DNA chip microarray was based on the detection of the pathogen-specific 16S rRNA gene. The bacterial DNA was extracted, and subsequently, parts of the 16S-rRNA-coded gene were amplified in the presence of fluorescence-labelled primer using polymerase chain reaction (PCR). The labelled and amplified parts were then hybridized to pathogen-specific DNA probes from the areas of the 16S rRNA gene that were spotted to the DNA chip. The measurement of bound DNA was carried out with microarray scanners. The limit of ª 2014 Wiley Publishing Asia Pty Ltd
*Intragroup comparison statistically-significant difference (P < 0.05), #P > 0.05; first P-value: NNRTI HAART vs PI HAART at baseline; second P-value: NNRTI HAART vs PI HAART after treatment. All data presented as medians, except for sex and smoking habits. CD4 counts in cells/lL blood; viral load in RNA copies/mL blood. CI, confidence interval; HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor; SPT, supportive periodontal therapy.
0.6/1.0 1.0/1.0# 0.9 – 1.0 –
0.4
– – –
–
0.9
0.6/0.6#
0.6/0.9
0.4/0.2
0.0 (0.0, 152,009) 0 (0, 0) 0.8 518 (37.6, 1178.0) 615 (136.6, 950.0) 0.8 0 (0, 0) 0.0 (0.0, 1.0) 1.0 7.5 (3.6, 10.4) 2.0 (0.0, 4.6) 0.1 27.5 (24.8, 29.3) 27.5 (23.7, 29.8) 1.0 50% 16 Male
35.0 (30.8, 40.7) – PI HAART
10.0 (2.3, 17.8) –
1.1 1.0 0.01* – – –
Intragroup comparison (P-value) Baseline After treatment Intragroup comparison (P-value)* Intergroup comparison (P-value)
After treatment
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–
–
–
1.0
2.0 (0.0, 4.6) 27.0 (23.3, 28.4)
395.5 (165.9, 665.6) 0 (0, 0)
8.0 (5.1, 12.3) 27.0 (23.3, 28.4) 57% 28 Male NNRTI HAART Baseline
40.0 (33.8, 42.8)
Sex Patient group Time
Age (years) (95% CI)
No. samples
Smoking habit
11.0 (2.8, 23.0)
Median no. pockets, 4–6 mm (95% CI)
0 (0.0, 1.2)
360 (0.0, 942.7)
28,060 (0.0, 89,246) 0.00 (0.0, 141,158) 0.9
Highly-active antiretroviral therapy
Median no. teeth (95% CI) Median months of SPT (95% CI)
Table 1. Clinical characteristics of patients with NNRTI HAART and PI HAART at baseline and after treatment
Median no. pockets >6 mm (95% CI)
Median CD4 counts (95% CI)
Median viral load (95% CI)
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detection of the ParoCheck 10 detecting periodontal pathogens was approximately 1476 copies per PCR (minimum: Prevotella intermedia [P. intermedia] 540 copies; maximum: Actinomyces viscosus [A. viscosus] 6013 copies). Tested pathogens were represented by the following complexes: red (Tannerella forsythia [T. forsythia], Porphyromonas gingivalis [P. gingivalis], Treponema denticola [T. denticola]), orange (Campylobacter rectus [C. rectus], Fusobacterium nucleatum [F. nucleatum], Parvimonas micra [P. micra], P. intermedia), and green (Eikenella corrodens [E. corrodens]. Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) exists in several serotypes (a–e). Serotype a was assigned to the green complex, whereas serotype b was not allocated to any complex.16 A. actinomycetemcomitans serotyping was not performed in this investigation. As a clinical investigation of the periodontal distribution of serotypes in a German population showed, A. actinomycetemcomitans serotype b was the most prevalent strain;17 therefore, A. actinomycetemcomitans, as well as A. viscosus were classified as pathogens that were not related to periodontal complexes in the present study. Statistical analysis Statistical analysis was calculated with Prism4 for Macintosh (Graphpad Software, San Diego, CA, USA). The primary outcome measure was the action of antiretroviral drug therapy on subgingival bacteria. Odds ratios (OR) for different HAART regimens were calculated with contingency tables. Statistical significance was determined using Fisher’s exact test, with P < 0.05. An intergroup comparison of clinical characteristics of the patients at baseline and after treatment was performed using the Mann–Whitney U-test; paired observations were analyzed using Wilcoxon signed rank test. Ethics The study was conducted to the provisions of the Declaration of Helsinki, including informed consent of the patients. The study was approved by the ethical review board of Witten/Herdecke University, Germany (16/2009). Results The clinical characteristics of the patients at baseline and after treatment are summarized in Table 1. They demonstrated neither statistically significant differences concerning demographic (age, sex), behavioral (smoking habits), periodontal (teeth with periodontitis, number of teeth, and duration of SPT) nor hematological and viremic (CD4 counts and viral load) baseline data (P > 0.05). No significant changes were observed in these parameters after treat67
Highly-active antiretroviral therapy
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PopulaƟon
HIV+
Inclusion criteria
HIV+, HAART, chronic periodonƟƟs, < 45 years of age, minimum 20 teeth, no anƟbioƟcs
n = 92
Dropout: 78 paƟents
n = 14
Periodontal intervenƟon
IniƟal hygiene phase, scaling and root planing (S/RP)
n = 14
SupporƟve periodontal therapy
Clinical re-evaluaƟon, oral hygiene instrucƟon, professional tooth cleaning
n = 14
Baseline measurement AŌer iniƟal hygiene phase Before scaling and root planning
Dropout: 3 paƟents Re-evaluaƟon inclusion criteria
HAART, minimum 20 teeth, no anƟbioƟcs
n = 11
NNRTI/HAART
Microbial tesƟng
AggregaƟbacter acƟnomycetemcomitans, AcƟnomyces viscosus, Tannerella forsythia Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Parvimonas micra, Treponema denƟcola.
n=4 n = 11
PI/HAART
AŌer treatment -measurement
n=7
Figure 1. Study design and flow of patients during the study. HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, nonnucleoside reverse transcriptase inhibitor.
68
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Highly-active antiretroviral therapy
250
Mean SNR
200 150 100 50
Figure 2. Distribution of periodontal pathogens in signal-to-noise ratio (SNR), grouped by nonnucleoside reverse transcriptase inhibitor highly-active antiretroviral therapy (HAART) (grey bars) and protease inhibitor HAART (black bars).
ac A tin g om gre C yc ga am e ti py tem bac lo co te ba m r Fu E ct ita so ike e n Po bac ell r re ns a c rp te c r hy iu or tus ro m ro nu de m n Pr on c ev as lea s tu ot g m el in gi Pa la i nt val r i vi Tr e m rm s e A pon on ed ct as ia e in m om a m i c d Ta yc en ra n es tic ac A ner vi ola tin g el sc o gr la os A my ega for us ct ce t sy i in o te ba th C my mc cte ia am c o r py es mit v a l Fu Ei oba isc ns ct os so ke u n e Po bac ell r re s c rp te a c hy riu or tus ro m ro m n d Pr on uc ens ev as lea ot t el gin um Pa la i giv n Tr rvi ter alis ep m m on on ed a Ta em s m ia nn a i er de cra n el la tic fo ola rs yt hi a
0
ment, except for the intragroup comparisons of the number of teeth with periodontal probing pocket depths between 4 and 6 mm (P < 0.05). The patients’ HAART regimens consisted of first-line therapies, including an NNRTI or a PI in combination with two RTI. One patient who received triple RTI combination therapy at recruitment was supplemented an NNRTI on short notice. In general, the highest prevalence was evident for pathogens of the red and orange complexes, but there was no statistically significant difference between NNRTI HAART and PI HAART (P > 0.5) (Figure 2). Some periodontal pathogens showed remarkable OR when compared with the different HAART regimens. In the PI HAART group, high OR were found when compared with NNRTI HAART for A. viscosus (OR: 303), C. rectus (OR: 90), and T. denticola (OR: 25); a borderline OR was found for the orange complex (OR: 5.0). The association between A. viscosus and PI HAART was statistically significant (P = 0.03). In the NNRTI HAART group, lower OR were documented. The highest OR was found for F. nucleatum (OR: 56), followed by E. corrodens (OR: 25). P. micra showed a borderline OR of 5.0 (Table 2). Discussion The present investigation found an association between key drugs of antiretroviral therapy, PI and NNRTI, and subgingival bacteria, which, to the best of our knowledge, has not been previously documented. A significant association was found for A. viscosus (OR: 303, P = 0.03) in the patients on PI HAART. C. rectus (OR: 90) and T. denticola (OR: 25) also showed high OR for protease inhibitors, whereas F. nucleatum (OR: 56) and E. corrodens (OR: 25) were more prevalent in NNRTI HAART. The results suggest an influence of PI and NNRTI containing HAART on the prevalence of subgingival bacteria. The OR we found were, to some extent, higher than descriptions of former clinical investigations, which presented OR of 2.6 for periodontal disease progression in patients undergoing zidovudine ª 2014 Wiley Publishing Asia Pty Ltd
Periodontal pathogens
antiretroviral therapy.12 The RTI inhibitor zidovudine is still used in contemporary HAART as a so-called backbone drug. The interactions between antiretroviral drugs and periodontal diseases have not yet been elucidated, but clinically, there seems to be more relevant constitution than general immune reconstitution under HAART that normalizes immune response in the HIV-infected patient. In the oral cavity, the mechanisms of HIV-related immune suppression were described as follows: (a) a limited chemotaxis of neutrophilic granulocytes in the initial phase of periodontal disease defense;18,19 (b) a dysfunction of macrophages with CD4 surface markers in the succeeding phase of phagocyte activity;20 and (c) a disorganization of gingival B- and T-lymphocyte activity and their humoral products, such as immune globulins.21 Based on this, all stages of the host-dependent immunological defense against periodontal disease are compromised by HIV infection. It was demonstrated in vitro and in vivo that PI has a negative effect on the viability and growth of Candida albicans (C. albicans). Both HIV-1 protease and the virulence factor secreted aspartyl proteinase of C. albicans belong to the aspartyl proteinase family, which is suppressed by antiretroviral protease inhibitors. These findings indicate the antifungal activity of PI.10,22 In a Greek study, a lack of reduction of oral lesions in patients on antiretroviral therapy without any key drug, even though presenting better hematological and viremic data when compared with that of patients on PI HAART, indicated that other factors, besides immune reconstitution, might affect oral lesion reduction in patients undergoing PI HAART.9 Only one study was found that addressed NNRTI and HIV-related oral lesions.13 In Aquino-Garcia et al.’s13 study, oral lesions were compared in patients on NNRTI HAART versus PI HAART. The results showed a significantly lower prevalence for HIV-related oral lesions in patients undergoing NNRTI HAART compared to PI HAART. Specifically, lower prevalence was documented for oral candidiasis, necrotizing ulcerative periodontitis, and non-specific oral lesions.13 In patients 69
70
528.7 556.6 358.8 56.1 320.8 1326 947
0, 0 9.7, 281.9 0.0, 29.4 0.0, 12.1 40.4, 371.9 0.0, 152.2 0.0, 193.8 11.3, 59.2 0.0, 248.9 84.2, 565.4 77.6, 556.6 0 133.4 8.1 0.0 184.2 7.3 8.4 34.8 0.0 336.5 296.4 0 5 3 1 6 3 3 5 5 2 1
CI, confidence interval; HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor; SNR, signal-to-noise ratio.
0.03 1.0 0.2 1.0 0.4 1.0 0.6 0.5 1.0 1.0 0.5 303.3 0.6 90.0 0.04 0.01 1.0 3.0 0.2 24.5 2.0 5.0 0.003 1.7 0.01 24.5 55.7 1.0 0.3 5.0 0.04 0.5 0.2 80.3 505.0 56.8
0.0, 0.0, 9.2, 0, 0 0.0, 0.0, 0.0, 0.0, 105.4, 0.0, 0.0, 22.7 235.5 35.9 0 163.0 47.4 38.5 8.0 190.9 446.4 248.7 3 3 4 0 3 2 3 2 4 2 2
1.0 1.7 0.6 0.0; 381.1 0.0 0.0 24 (n = 6 patients)
1
0.0, 19.2
16 (n = 4 patients)
1
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Aggregatibacter actinomycetemcomitans Actinomyces viscosus Tannerella forsythia Campylobacter rectus Eikenella corrodens Fusobacterium nucleatum Porphyromonas gingivalis Prevotella intermedia Parvimonas micros Treponema denticola Red complex Orange complex
No. samples Periodontal pathogens and complexes
No. samples
Positivelytested patients
Median SNR
95% CI
PI/HAART NNRTI/HAART
Table 2. Odds ratios for periodontal pathogens associated with PI HAART and NNRTI HAART
Positivelytested patients
Median SNR
95% CI
Odds ratio of positive number of patients with PI as reference HAART and NNRTI as HAART at risk
Odds ratio of positive number of patients with NNRTI as reference HAART and PI as HAART at risk P-value
Highly-active antiretroviral therapy
with chronic periodontitis, it was evident that HIV-infected patients undergoing HAART had significantly improved periodontal health after scaling and root planing and supportive periodontal therapy. The average pocket reduction was 1.7 mm, demonstrating no significant difference compared with a HIV-seronegative control group.23 Another study showed that SPT in HIV-infected patients was able to improve gingival health significantly by 50%.24 These clinical findings demonstrate that HIV-infected patients on HAART could be periodontally treated according to the current treatment concepts. However, it was also noticed that HIV-related oral lesions increased again with the duration of HAART, suggesting that opportunistic HIV-related oral lesions might form part of the clinical picture of immune reconstitution inflammatory syndrome, although that infections were of late onset.25 While it is advantageous to have first clinical and microbiological data for patients with chronic periodontitis undergoing different HAART regimens, this work has several limitations. The sample of patients was small and included only two commonly-used HAART regimens. Therefore, the risk of bias is substantial. No microbial testing was performed at baseline for comparison after treatment. However, recolonization of the subgingival biofilm in periodontal pockets after scaling and root planing takes up to 60 days to reach pretreatment values.26 In this respect, the different durations of supportive periodontal therapies documented in the present study would not be expected to be a confounding factor. The patients were also treated according to a standard procedure before microbial testing for clinical standardization of the study population. This could be verified by the intergroup and intragroup statistical comparisons. However, the number of periodontal pathogens in subgingival biofilms far exceeds the 10 tested bacterial species. It has been shown that more than 700 species colonize the oral cavity.27 Future directions for this particular research collaboration include the verification of the results in a larger cohort, including other HAART regimens, as well as a longitudinal and clinically-accompanied observation of these patients to evaluate clinical relevance. It is of further interest to scrutinize the cellular/molecular effect of antiretroviral drugs on periodontal pathogens, as shown before in Candida species. Conclusion The results of the present study demonstrated statistical associations between subgingival bacteria and antiretroviral drug therapies. These preliminary results support the generation of a working hypothesis that different antiretroviral therapies might have an influence on subgingival bacteria. Further investigation on the clinical significance and underlying mechanisms are needed to support these findings. ª 2014 Wiley Publishing Asia Pty Ltd
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References 1 Tenenbaum H, Mock D, Simor A. Periodontitis as an early presentation of HIV infection. Can Med Assoc J 1991; 144: 1265–9. 2 Winkler JR, Robertson RB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992; 73: 145. 3 Logie C, Gadalla TM. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care 2009; 21: 742–53. 4 Mataftsi M, Skoura L, Sakellari D. HIV infection and periodontal diseases: an overview of the post-HAART era. Oral Dis 2011; 17: 13–25. 5 Schmidt-Westhausen A, Priepke F, Bergmann F, Reichart P. Decline in the rate of oral opportunistic infections following introduction of highly active antiretroviral therapy. J Oral Pathol Med 2000; 29: 336–41. 6 Greenspan D, Canchola A, MacPhail L, Cheikh B, Greenspan J. Effect of highly active antiretroviral therapy on frequency of oral warts. Lancet 2001; 357: 1411–2. 7 Ceballos-Salobrena A, Gaitan-Cepeda L, Ceballos-Garcia L, Lezama-Del Valle D. Oral lesions in HIV/AIDS patients undergoing highly active antiretroviral treatment including protease inhibitors: a new face of oral AIDS? AIDS Patient Care STDS 2000; 14: 627–35. 8 Taiwo OO, Hassan Z. The impact of HAART on the clinical features of HIV-related oral lesions in Nigeria. AIDS Res Ther 2010; 7: 19. 9 Nicolatou-Galitis O, Velegraki A, Paikos S et al. Effect of PI-HAART of oral lesions in HIV-1 infected patients. A Greek study. Oral Dis 2004; 10: 145–50. 10 Cassone A, Tacconelli E, De Bernardis F et al. Antiretroviral therapy with protease inhibitors has an early, immune reconstitution-independent beneficial effect on Canidida virulence
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and oral candidiasis in human immunodeficiency virus-infected subjects. J Infect Dis 2002; 185: 188–95. Goncalves de Souza L, Soares Ferreira SM, Souza CO, Souto R, Colombo AP. Clinical and microbiological profile of human immunodeficiency virus (HIV)-seropositive Brazilians undergoing highly active anti-retroviral therapy and HIV-seronegative Brazilians with chronic periodontitis. J Periodontol 2007; 78: 87–96. Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995; 66: 421–8. Aquino-Garcia SI, Rivas MA, Ceballos-Salobrena A, Acosta Gio AE, Gaitan-Cepeda LA. Oral lesions in HIV/ AIDS patients undergoing HAART including efavirenz. AIDS Res Hum Retroviruses 2008; 24: 815–20. Holbrook WP, Oskarsdottir A, Fridjonsson T, Einarsson H, Hauksson A, Geirsson RT. No link between lowgrade periodontal disease and preterm birth: a pilot study in a healthy Caucasian population. Acta Odontol Scand 2004; 62: 177–9. Haffajee AD, Socransky SS. Effect of sampling strategy on the false-negative rate for detection of selected subgingival species. Oral Microbiol Immunol 1992; 7: 57–9. Socransky SS, Smith C, Haffajee AD. Subgingival microbial profiles in refractory periodontal disease. J Clin Periodontol 2002; 29: 260–8. Kim TS, Frank P, Eickholz P, Eick S, Kim CK. Serotypes of Aggregatibacter actinomycetemcomitans in patients with different ethnic backgrounds. J Periodontol 2009; 80: 2020–7. Lazzarin A, Uberti Foppa C, Galli M et al. Impairment of polymorphnuclear leucocyte function in patients with acquired immunodeficiency syndrome and with lymphadenopathy syndrome. Clin Exp Immunol 1986; 65: 105–11.
19 Ras GJ, Eftychis HA, Anderson R, van der Waal I. Mononuclear and polymorphnuclear leucocyte dysfunction in male homosexuals with AIDS. S Afr Med J 1984; 66: 806–9. 20 Perno C, Newcomb F, Davis D et al. Relative potency of protease inhibitors in monocyte/macrophages acutely and chronically infected with human immunodeficiency virus. J Infect Dis 1998; 178: 413–22. 21 Myint M, Odden K, Schreurs O, Halstensen T, Schenck K. The gingival plasma cell infiltrate in HIV-positive patients with periodontitis is disorganized. J Clin Periodontol 1999; 26: 358–65. 22 Gruber A, Speth C, Lukasser-Vogl E et al. Human immunodeficiency virus type 1 protease inhibitor attenuates Candida albicans virulence properties in vitro. Immunopharmacology 1999; 41: 227–34. 23 Jordan RA, G€angler P, J€ ohren P. Clinical treatment outcomes of periodontal therapy in HIV-seropositive patients undergoing highly antiretroviral therapy. Eur J Med Res 2005; 11: 232–5. 24 Lemos SS, Oliviera FA, Venico EF. Periodontal diseases and oral hygiene benefits in HIV seropositive and AIDS patients. Med Oral Patol Oral Cir Bucal 2010; 35: e417–21. 25 Gaitan Cepeda LA, Ceballos Salobrena A, Lopez Ortega K, Arzate Mora N, Jimenez Soriano Y. Oral lesions and immune reconstitution syndrome in HIV+/AIDS patients receiving highly active anti-retroviral therapy. Epidemiological evidence. Med Oral Patol Oral Cir Bucal 2008; 13: E85–92. 26 Sbordone L, Ramaglia L, Guiletta E, Iacono V. Recolonization of the subgingival microflora after scaling and root planing in human periodontitis. J Periodontol 1990; 61: 579–84. 27 Kilian M. Facing facts - Making sense of oral infections. Oral Biosci Med 2005; 2: 163–5.
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ORIGINAL ARTICLE Oral Medicine
Influence of highly-active antiretroviral therapy on the subgingival biofilm in HIV-infected patients Rainer A. Jordan1, Adrian Lucaciu2 & Stefan Zimmer1 1 Department of Operative and Preventive Dentistry, Faculty of Health, Witten/Herdecke University, Witten, Germany 2 Private Practice, Cologne, Germany
Keywords antiretroviral drug, highly-active antiretroviral therapy, HIV infection, periodontal disease, subgingival biofilm. Correspondence Dr Rainer A. Jordan, Director, Institute of German Dentists (IDZ), Universitaetsstrasse 73, Cologne D-50931, Germany. Tel: +49-221-4001-145 Fax: +49-221-404886 Email: [email protected] Received 8 July 2013; accepted 27 July 2013. doi: 10.1111/jicd.12124
Abstract Aim: Highly-active antiretroviral therapy (HAART) has been associated with alterations in subgingival biofilm and periodontal disease. The purpose of the present study was to investigate the association between different HAART regimens and the prevalence of periodontal pathogens in HIV-infected patients with chronic periodontitis. Methods: Subgingival periodontal pathogens were determined by a DNA chip microarray in a case series in 14 HIV-infected patients receiving HAART with different drug combinations: protease inhibitor (PI)-based HAART versus nonnucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. A statistical analysis was conducted to determine whether specific HAART regimens were associated with 10 periodontal pathogens using odds ratios (OR). Results: At baseline and after treatment, the patients did not show significant clinical and immunological differences. In general, the highest OR for the prevalence of periodontal pathogens were found in the PI HAART group for Actinomyces viscosus (A. viscosus) (OR: 303), Campylobacter rectus (OR: 90), and Treponema denticola (OR: 25). In the NNRTI HAART group, higher OR were documented for Fusobacterium nucleatum (OR: 56) and Eikenella corrodens (OR: 25). The association between A. viscosus and PI HAART was statistically significant (P = 0.03). Conclusions: The results demonstrated statistical associations between subgingival bacteria and antiretroviral drug therapies. Further investigation on the clinical significance and underlying mechanisms are needed to support these findings.
Introduction Microbiological studies in HIV-infected patients have been conducted since the beginning of the worldwide epidemic, but less is known about antiretroviral drug influences on periodontal pathogens. The scientific investigation of the subgingival biofilm in HIV-infected patients can be divided into different stages. First, investigations before 1996, the time of the development of highly-active antiretroviral therapy (HAART), when periodontal pathogens were studied in the natural progression of HIV infection; second, investigations after 1996. Pre-HAART results have demonstrated a high prevalence of periodontal diseases, especially acute forms, such as necrotizing ulcerative gingivitis and periodontitis, ª 2014 Wiley Publishing Asia Pty Ltd
accompanied by high levels of periodontal and atypical microbiota.1,2 HAART has shifted HIV infection into a chronic disease, with a significantly decreased mortality and improved quality of life.3,4 This includes a changing prevalence in HIV-related and AIDS-indicating diseases of the oral cavity, such as Kaposi sarcoma, but also new HIV-related oral lesions, such as oral warts.5,6 However, the overall preventive fraction of HIV-related oral lesions in patients undergoing protease inhibitor (PI)-based HAART is approximately 30%.7 Bacterial and fungal infections, in particular, decreased significantly under HAART, whereas oral lesions of viral or autoimmune origin, as well as neoplasia, have been found to have a significant impact in some populations.8 Scientific evidence of the role of specific antiretroviral drugs, such as the key medicine protease 65
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inhibitors and non-nucleoside reverse transcriptase inhibitors (NNRTI), is inconsistent. Protease inhibitors are widely investigated, demonstrating a significant effect in preventing HIV-related oral lesions compared to PI-sparing drug regimens.9 For instance, several clinical and in vitro investigations have demonstrated a direct, immune reconstitution-independent effect of PI on the prevalence of oral candidiasis.10 In a Brazilian cohort, HIV-infected patients with chronic periodontitis undergoing HAART showed even less periodontal inflammation and destruction, as compared to a HIV-seronegative control group with chronic periodontitis. This effect was also obvious in patients on semi-optimal HAART with immunosuppression and detectable viremia, indicating that there might be a HAART-dependent protective effect in the clinical course of periodontal diseases, as well as general immune reconstitution. The study also revealed a significant difference in the subgingival bacterial load and elevated levels of microbiota of the red and orange complex in the HIV-seronegative control group for the benefit of HAART patients.11 However, it was also shown that reverse transcriptase inhibitors (RTI) are able to compromise periodontal health,12 and epidemiological studies have shown significantly more HIV-related oral lesions in patients on PI HAART compared to those taking an NNRTI HAART, with twice the amount of oral lesions.13 The findings indicate an influence of HAART drug regimens in the development of HIV-related oral lesions, particularly bacterial infections. Microbiological investigations of the subgingival biofilm composition in HIVinfected patients undergoing HAART have demonstrated clear differences compared to an HIV-seronegative control group,11 yet no data are available concerning the potential influence of different antiretroviral key drugs (PI, NNRTI) on periodontal pathogens, restricting the development of a working hypothesis. Therefore, the aim of this preliminary investigation was to analyze differences in the subgingival profile of HIV-infected patients with chronic periodontitis on supportive periodontal therapy (SPT) undergoing different HAART regimens to generate a working hypothesis for a prospective clinical study. Material and methods Patients attending an outpatient HIV oral health care center in Berlin, Germany, who were undergoing HAART for at least 6 months, and who had chronic periodontitis, were asked to participate in the study. They were recruited within a time slot of 12 months, meeting the primary inclusion criteria (HIV-1 infection and NNRTI or PI as a key drug of HAART; n = 92). Periodontal disease was defined as a minimum of four teeth with periodontal probing pocket depths ≥4 mm.14 Periodontal examination was 66
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performed using a PCP 12 periodontometer (HuFridey, Chicago, IL, USA) by a calibrated examiner (intra-examiner reliability: K = 0.91). After screening for the secondary inclusion criteria (chronic periodontitis with at least 4 teeth with probing pocket depths of ≥4 mm and younger than 45 years of age), 14 patients met the initial inclusion criteria for participation. Of these, 11 concluded the study. Exclusion criteria were the presence of other systemic disorders associated with chronic periodontitis, such as diabetes; patients taking antibiotics at least 3 months prior to the examinations, at baseline, and after treatment; and a lack of compliance concerning SPT and informed consent, respectively. The patients were periodontally treated according to a standard therapy protocol. Scaling and root planing was performed by a single operator, and SPT by a single dental hygienist, respectively. After three appointments of an initial hygiene phase with professional tooth cleaning and oral hygiene instructions at 2-week intervals, the baseline measurement of clinical parameters of periodontal, hematological, and viremic data was done (Table 1). Subsequently, scaling and root planing was performed in all teeth with periodontal probing pocket depths ≥4 mm, followed by SPT with an appointment schedule according to the individual risk profile. Approximately 10.6 months after scaling and root planing and 3 months prior to study commencement, patients were rescreened for antibiotics; three patients were excluded from the study. Clinical characteristics were rerecorded, 10 periodontal pathogens were detected by a DNA chip microarray, and statistical analysis was performed (Figure 1). Measurement of periodontal pathogens The detection of periodontal pathogens was executed with ParoCheck 10 (Greiner BioOne GmbH, Frickenhausen, Germany). According to the recommendations of Haffajee and Socransky15, biofilm samples were taken for 15 s in the four deepest pockets with sterile paper tips. Twenty-eight unpooled samples in seven patients with NNRTI HAART, and 16 unpooled samples in four patients with PI HAART, were thus obtained from sites with previous scaling and root planing. They were transferred into sterile collection tubes, and transported to the microbiological lab at room temperature. The test principle of the DNA chip microarray was based on the detection of the pathogen-specific 16S rRNA gene. The bacterial DNA was extracted, and subsequently, parts of the 16S-rRNA-coded gene were amplified in the presence of fluorescence-labelled primer using polymerase chain reaction (PCR). The labelled and amplified parts were then hybridized to pathogen-specific DNA probes from the areas of the 16S rRNA gene that were spotted to the DNA chip. The measurement of bound DNA was carried out with microarray scanners. The limit of ª 2014 Wiley Publishing Asia Pty Ltd
*Intragroup comparison statistically-significant difference (P < 0.05), #P > 0.05; first P-value: NNRTI HAART vs PI HAART at baseline; second P-value: NNRTI HAART vs PI HAART after treatment. All data presented as medians, except for sex and smoking habits. CD4 counts in cells/lL blood; viral load in RNA copies/mL blood. CI, confidence interval; HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor; SPT, supportive periodontal therapy.
0.6/1.0 1.0/1.0# 0.9 – 1.0 –
0.4
– – –
–
0.9
0.6/0.6#
0.6/0.9
0.4/0.2
0.0 (0.0, 152,009) 0 (0, 0) 0.8 518 (37.6, 1178.0) 615 (136.6, 950.0) 0.8 0 (0, 0) 0.0 (0.0, 1.0) 1.0 7.5 (3.6, 10.4) 2.0 (0.0, 4.6) 0.1 27.5 (24.8, 29.3) 27.5 (23.7, 29.8) 1.0 50% 16 Male
35.0 (30.8, 40.7) – PI HAART
10.0 (2.3, 17.8) –
1.1 1.0 0.01* – – –
Intragroup comparison (P-value) Baseline After treatment Intragroup comparison (P-value)* Intergroup comparison (P-value)
After treatment
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–
–
–
1.0
2.0 (0.0, 4.6) 27.0 (23.3, 28.4)
395.5 (165.9, 665.6) 0 (0, 0)
8.0 (5.1, 12.3) 27.0 (23.3, 28.4) 57% 28 Male NNRTI HAART Baseline
40.0 (33.8, 42.8)
Sex Patient group Time
Age (years) (95% CI)
No. samples
Smoking habit
11.0 (2.8, 23.0)
Median no. pockets, 4–6 mm (95% CI)
0 (0.0, 1.2)
360 (0.0, 942.7)
28,060 (0.0, 89,246) 0.00 (0.0, 141,158) 0.9
Highly-active antiretroviral therapy
Median no. teeth (95% CI) Median months of SPT (95% CI)
Table 1. Clinical characteristics of patients with NNRTI HAART and PI HAART at baseline and after treatment
Median no. pockets >6 mm (95% CI)
Median CD4 counts (95% CI)
Median viral load (95% CI)
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detection of the ParoCheck 10 detecting periodontal pathogens was approximately 1476 copies per PCR (minimum: Prevotella intermedia [P. intermedia] 540 copies; maximum: Actinomyces viscosus [A. viscosus] 6013 copies). Tested pathogens were represented by the following complexes: red (Tannerella forsythia [T. forsythia], Porphyromonas gingivalis [P. gingivalis], Treponema denticola [T. denticola]), orange (Campylobacter rectus [C. rectus], Fusobacterium nucleatum [F. nucleatum], Parvimonas micra [P. micra], P. intermedia), and green (Eikenella corrodens [E. corrodens]. Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) exists in several serotypes (a–e). Serotype a was assigned to the green complex, whereas serotype b was not allocated to any complex.16 A. actinomycetemcomitans serotyping was not performed in this investigation. As a clinical investigation of the periodontal distribution of serotypes in a German population showed, A. actinomycetemcomitans serotype b was the most prevalent strain;17 therefore, A. actinomycetemcomitans, as well as A. viscosus were classified as pathogens that were not related to periodontal complexes in the present study. Statistical analysis Statistical analysis was calculated with Prism4 for Macintosh (Graphpad Software, San Diego, CA, USA). The primary outcome measure was the action of antiretroviral drug therapy on subgingival bacteria. Odds ratios (OR) for different HAART regimens were calculated with contingency tables. Statistical significance was determined using Fisher’s exact test, with P < 0.05. An intergroup comparison of clinical characteristics of the patients at baseline and after treatment was performed using the Mann–Whitney U-test; paired observations were analyzed using Wilcoxon signed rank test. Ethics The study was conducted to the provisions of the Declaration of Helsinki, including informed consent of the patients. The study was approved by the ethical review board of Witten/Herdecke University, Germany (16/2009). Results The clinical characteristics of the patients at baseline and after treatment are summarized in Table 1. They demonstrated neither statistically significant differences concerning demographic (age, sex), behavioral (smoking habits), periodontal (teeth with periodontitis, number of teeth, and duration of SPT) nor hematological and viremic (CD4 counts and viral load) baseline data (P > 0.05). No significant changes were observed in these parameters after treat67
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PopulaƟon
HIV+
Inclusion criteria
HIV+, HAART, chronic periodonƟƟs, < 45 years of age, minimum 20 teeth, no anƟbioƟcs
n = 92
Dropout: 78 paƟents
n = 14
Periodontal intervenƟon
IniƟal hygiene phase, scaling and root planing (S/RP)
n = 14
SupporƟve periodontal therapy
Clinical re-evaluaƟon, oral hygiene instrucƟon, professional tooth cleaning
n = 14
Baseline measurement AŌer iniƟal hygiene phase Before scaling and root planning
Dropout: 3 paƟents Re-evaluaƟon inclusion criteria
HAART, minimum 20 teeth, no anƟbioƟcs
n = 11
NNRTI/HAART
Microbial tesƟng
AggregaƟbacter acƟnomycetemcomitans, AcƟnomyces viscosus, Tannerella forsythia Campylobacter rectus, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Parvimonas micra, Treponema denƟcola.
n=4 n = 11
PI/HAART
AŌer treatment -measurement
n=7
Figure 1. Study design and flow of patients during the study. HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, nonnucleoside reverse transcriptase inhibitor.
68
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250
Mean SNR
200 150 100 50
Figure 2. Distribution of periodontal pathogens in signal-to-noise ratio (SNR), grouped by nonnucleoside reverse transcriptase inhibitor highly-active antiretroviral therapy (HAART) (grey bars) and protease inhibitor HAART (black bars).
ac A tin g om gre C yc ga am e ti py tem bac lo co te ba m r Fu E ct ita so ike e n Po bac ell r re ns a c rp te c r hy iu or tus ro m ro nu de m n Pr on c ev as lea s tu ot g m el in gi Pa la i nt val r i vi Tr e m rm s e A pon on ed ct as ia e in m om a m i c d Ta yc en ra n es tic ac A ner vi ola tin g el sc o gr la os A my ega for us ct ce t sy i in o te ba th C my mc cte ia am c o r py es mit v a l Fu Ei oba isc ns ct os so ke u n e Po bac ell r re s c rp te a c hy riu or tus ro m ro m n d Pr on uc ens ev as lea ot t el gin um Pa la i giv n Tr rvi ter alis ep m m on on ed a Ta em s m ia nn a i er de cra n el la tic fo ola rs yt hi a
0
ment, except for the intragroup comparisons of the number of teeth with periodontal probing pocket depths between 4 and 6 mm (P < 0.05). The patients’ HAART regimens consisted of first-line therapies, including an NNRTI or a PI in combination with two RTI. One patient who received triple RTI combination therapy at recruitment was supplemented an NNRTI on short notice. In general, the highest prevalence was evident for pathogens of the red and orange complexes, but there was no statistically significant difference between NNRTI HAART and PI HAART (P > 0.5) (Figure 2). Some periodontal pathogens showed remarkable OR when compared with the different HAART regimens. In the PI HAART group, high OR were found when compared with NNRTI HAART for A. viscosus (OR: 303), C. rectus (OR: 90), and T. denticola (OR: 25); a borderline OR was found for the orange complex (OR: 5.0). The association between A. viscosus and PI HAART was statistically significant (P = 0.03). In the NNRTI HAART group, lower OR were documented. The highest OR was found for F. nucleatum (OR: 56), followed by E. corrodens (OR: 25). P. micra showed a borderline OR of 5.0 (Table 2). Discussion The present investigation found an association between key drugs of antiretroviral therapy, PI and NNRTI, and subgingival bacteria, which, to the best of our knowledge, has not been previously documented. A significant association was found for A. viscosus (OR: 303, P = 0.03) in the patients on PI HAART. C. rectus (OR: 90) and T. denticola (OR: 25) also showed high OR for protease inhibitors, whereas F. nucleatum (OR: 56) and E. corrodens (OR: 25) were more prevalent in NNRTI HAART. The results suggest an influence of PI and NNRTI containing HAART on the prevalence of subgingival bacteria. The OR we found were, to some extent, higher than descriptions of former clinical investigations, which presented OR of 2.6 for periodontal disease progression in patients undergoing zidovudine ª 2014 Wiley Publishing Asia Pty Ltd
Periodontal pathogens
antiretroviral therapy.12 The RTI inhibitor zidovudine is still used in contemporary HAART as a so-called backbone drug. The interactions between antiretroviral drugs and periodontal diseases have not yet been elucidated, but clinically, there seems to be more relevant constitution than general immune reconstitution under HAART that normalizes immune response in the HIV-infected patient. In the oral cavity, the mechanisms of HIV-related immune suppression were described as follows: (a) a limited chemotaxis of neutrophilic granulocytes in the initial phase of periodontal disease defense;18,19 (b) a dysfunction of macrophages with CD4 surface markers in the succeeding phase of phagocyte activity;20 and (c) a disorganization of gingival B- and T-lymphocyte activity and their humoral products, such as immune globulins.21 Based on this, all stages of the host-dependent immunological defense against periodontal disease are compromised by HIV infection. It was demonstrated in vitro and in vivo that PI has a negative effect on the viability and growth of Candida albicans (C. albicans). Both HIV-1 protease and the virulence factor secreted aspartyl proteinase of C. albicans belong to the aspartyl proteinase family, which is suppressed by antiretroviral protease inhibitors. These findings indicate the antifungal activity of PI.10,22 In a Greek study, a lack of reduction of oral lesions in patients on antiretroviral therapy without any key drug, even though presenting better hematological and viremic data when compared with that of patients on PI HAART, indicated that other factors, besides immune reconstitution, might affect oral lesion reduction in patients undergoing PI HAART.9 Only one study was found that addressed NNRTI and HIV-related oral lesions.13 In Aquino-Garcia et al.’s13 study, oral lesions were compared in patients on NNRTI HAART versus PI HAART. The results showed a significantly lower prevalence for HIV-related oral lesions in patients undergoing NNRTI HAART compared to PI HAART. Specifically, lower prevalence was documented for oral candidiasis, necrotizing ulcerative periodontitis, and non-specific oral lesions.13 In patients 69
70
528.7 556.6 358.8 56.1 320.8 1326 947
0, 0 9.7, 281.9 0.0, 29.4 0.0, 12.1 40.4, 371.9 0.0, 152.2 0.0, 193.8 11.3, 59.2 0.0, 248.9 84.2, 565.4 77.6, 556.6 0 133.4 8.1 0.0 184.2 7.3 8.4 34.8 0.0 336.5 296.4 0 5 3 1 6 3 3 5 5 2 1
CI, confidence interval; HAART, highly-active antiretroviral therapy; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor; SNR, signal-to-noise ratio.
0.03 1.0 0.2 1.0 0.4 1.0 0.6 0.5 1.0 1.0 0.5 303.3 0.6 90.0 0.04 0.01 1.0 3.0 0.2 24.5 2.0 5.0 0.003 1.7 0.01 24.5 55.7 1.0 0.3 5.0 0.04 0.5 0.2 80.3 505.0 56.8
0.0, 0.0, 9.2, 0, 0 0.0, 0.0, 0.0, 0.0, 105.4, 0.0, 0.0, 22.7 235.5 35.9 0 163.0 47.4 38.5 8.0 190.9 446.4 248.7 3 3 4 0 3 2 3 2 4 2 2
1.0 1.7 0.6 0.0; 381.1 0.0 0.0 24 (n = 6 patients)
1
0.0, 19.2
16 (n = 4 patients)
1
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Aggregatibacter actinomycetemcomitans Actinomyces viscosus Tannerella forsythia Campylobacter rectus Eikenella corrodens Fusobacterium nucleatum Porphyromonas gingivalis Prevotella intermedia Parvimonas micros Treponema denticola Red complex Orange complex
No. samples Periodontal pathogens and complexes
No. samples
Positivelytested patients
Median SNR
95% CI
PI/HAART NNRTI/HAART
Table 2. Odds ratios for periodontal pathogens associated with PI HAART and NNRTI HAART
Positivelytested patients
Median SNR
95% CI
Odds ratio of positive number of patients with PI as reference HAART and NNRTI as HAART at risk
Odds ratio of positive number of patients with NNRTI as reference HAART and PI as HAART at risk P-value
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with chronic periodontitis, it was evident that HIV-infected patients undergoing HAART had significantly improved periodontal health after scaling and root planing and supportive periodontal therapy. The average pocket reduction was 1.7 mm, demonstrating no significant difference compared with a HIV-seronegative control group.23 Another study showed that SPT in HIV-infected patients was able to improve gingival health significantly by 50%.24 These clinical findings demonstrate that HIV-infected patients on HAART could be periodontally treated according to the current treatment concepts. However, it was also noticed that HIV-related oral lesions increased again with the duration of HAART, suggesting that opportunistic HIV-related oral lesions might form part of the clinical picture of immune reconstitution inflammatory syndrome, although that infections were of late onset.25 While it is advantageous to have first clinical and microbiological data for patients with chronic periodontitis undergoing different HAART regimens, this work has several limitations. The sample of patients was small and included only two commonly-used HAART regimens. Therefore, the risk of bias is substantial. No microbial testing was performed at baseline for comparison after treatment. However, recolonization of the subgingival biofilm in periodontal pockets after scaling and root planing takes up to 60 days to reach pretreatment values.26 In this respect, the different durations of supportive periodontal therapies documented in the present study would not be expected to be a confounding factor. The patients were also treated according to a standard procedure before microbial testing for clinical standardization of the study population. This could be verified by the intergroup and intragroup statistical comparisons. However, the number of periodontal pathogens in subgingival biofilms far exceeds the 10 tested bacterial species. It has been shown that more than 700 species colonize the oral cavity.27 Future directions for this particular research collaboration include the verification of the results in a larger cohort, including other HAART regimens, as well as a longitudinal and clinically-accompanied observation of these patients to evaluate clinical relevance. It is of further interest to scrutinize the cellular/molecular effect of antiretroviral drugs on periodontal pathogens, as shown before in Candida species. Conclusion The results of the present study demonstrated statistical associations between subgingival bacteria and antiretroviral drug therapies. These preliminary results support the generation of a working hypothesis that different antiretroviral therapies might have an influence on subgingival bacteria. Further investigation on the clinical significance and underlying mechanisms are needed to support these findings. ª 2014 Wiley Publishing Asia Pty Ltd
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and oral candidiasis in human immunodeficiency virus-infected subjects. J Infect Dis 2002; 185: 188–95. Goncalves de Souza L, Soares Ferreira SM, Souza CO, Souto R, Colombo AP. Clinical and microbiological profile of human immunodeficiency virus (HIV)-seropositive Brazilians undergoing highly active anti-retroviral therapy and HIV-seronegative Brazilians with chronic periodontitis. J Periodontol 2007; 78: 87–96. Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995; 66: 421–8. Aquino-Garcia SI, Rivas MA, Ceballos-Salobrena A, Acosta Gio AE, Gaitan-Cepeda LA. Oral lesions in HIV/ AIDS patients undergoing HAART including efavirenz. AIDS Res Hum Retroviruses 2008; 24: 815–20. Holbrook WP, Oskarsdottir A, Fridjonsson T, Einarsson H, Hauksson A, Geirsson RT. No link between lowgrade periodontal disease and preterm birth: a pilot study in a healthy Caucasian population. Acta Odontol Scand 2004; 62: 177–9. Haffajee AD, Socransky SS. Effect of sampling strategy on the false-negative rate for detection of selected subgingival species. Oral Microbiol Immunol 1992; 7: 57–9. Socransky SS, Smith C, Haffajee AD. Subgingival microbial profiles in refractory periodontal disease. J Clin Periodontol 2002; 29: 260–8. Kim TS, Frank P, Eickholz P, Eick S, Kim CK. Serotypes of Aggregatibacter actinomycetemcomitans in patients with different ethnic backgrounds. J Periodontol 2009; 80: 2020–7. Lazzarin A, Uberti Foppa C, Galli M et al. Impairment of polymorphnuclear leucocyte function in patients with acquired immunodeficiency syndrome and with lymphadenopathy syndrome. Clin Exp Immunol 1986; 65: 105–11.
19 Ras GJ, Eftychis HA, Anderson R, van der Waal I. Mononuclear and polymorphnuclear leucocyte dysfunction in male homosexuals with AIDS. S Afr Med J 1984; 66: 806–9. 20 Perno C, Newcomb F, Davis D et al. Relative potency of protease inhibitors in monocyte/macrophages acutely and chronically infected with human immunodeficiency virus. J Infect Dis 1998; 178: 413–22. 21 Myint M, Odden K, Schreurs O, Halstensen T, Schenck K. The gingival plasma cell infiltrate in HIV-positive patients with periodontitis is disorganized. J Clin Periodontol 1999; 26: 358–65. 22 Gruber A, Speth C, Lukasser-Vogl E et al. Human immunodeficiency virus type 1 protease inhibitor attenuates Candida albicans virulence properties in vitro. Immunopharmacology 1999; 41: 227–34. 23 Jordan RA, G€angler P, J€ ohren P. Clinical treatment outcomes of periodontal therapy in HIV-seropositive patients undergoing highly antiretroviral therapy. Eur J Med Res 2005; 11: 232–5. 24 Lemos SS, Oliviera FA, Venico EF. Periodontal diseases and oral hygiene benefits in HIV seropositive and AIDS patients. Med Oral Patol Oral Cir Bucal 2010; 35: e417–21. 25 Gaitan Cepeda LA, Ceballos Salobrena A, Lopez Ortega K, Arzate Mora N, Jimenez Soriano Y. Oral lesions and immune reconstitution syndrome in HIV+/AIDS patients receiving highly active anti-retroviral therapy. Epidemiological evidence. Med Oral Patol Oral Cir Bucal 2008; 13: E85–92. 26 Sbordone L, Ramaglia L, Guiletta E, Iacono V. Recolonization of the subgingival microflora after scaling and root planing in human periodontitis. J Periodontol 1990; 61: 579–84. 27 Kilian M. Facing facts - Making sense of oral infections. Oral Biosci Med 2005; 2: 163–5.
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